FLIGHT SAFETY FOUNDATION Accident Prevention Vol. 61 No. 6 For Everyone Concerned With the Safety of Flight June 2004

Failure to Comply With Nonprecision Approach Procedure Sets Stage for Regional Jet CFIT at Zürich

The fl ight crew did not have visual contact with the runway or with the approach lights when they continued descent below the published minimum descent altitude. The airplane struck terrain soon after the crew began a missed approach.

FSF Editorial Staff

At 2206 local time Nov. 24, 2001, the fl ight crew • “In the approach sector of Runway 28 at Zürich of a British Aerospace (now BAE Systems) Avro Airport, there was no system available which 146-RJ100 operated by Crossair was conducting the triggers an alarm if a minimum safe altitude very-high-frequency omnidirectional radio/distance- is violated (minimum safe altitude warning measuring equipment (VOR/DME) approach to — MSAW); Runway 28 at Zürich () Airport in nighttime instrument meteorological conditions • “Over a long period of time, the responsible persons (IMC) when the airplane struck terrain. The two of the did not make correct assessments pilots, one cabin crewmember and 21 passengers were of the commander’s fl ying performance. Where killed; one cabin crewmember and four passengers weaknesses were perceptible, they did not take received serious injuries; and one cabin crewmember appropriate measures; and three passengers received minor injuries or no injuries. • “The commander’s ability to concentrate and take appropriate decisions, as well as his ability The Swiss Aircraft Accident Investigation Bureau (AAIB; Büro to analyze complex processes, were adversely für Flugunfalluntersuchungen) said, in its fi nal report on the affected by fatigue; accident, that the following were causal factors: • “Task-sharing between the flight crew during the approach was not appropriate and did not correspond to • “The commander deliberately descended below the the required procedures [of] the airline; minimum descent altitude (MDA) of the standard VOR/ DME approach … without having the required visual • “The range of hills which the aircraft came into contact contact [with] the approach lights or the runway; [and,] with was not marked on the approach chart used by the fl ight crew; • “The copilot made no attempt to prevent the continuation of the fl ight below the [MDA].” • “The means of determining the meteorological visibility at the airport was not representative for the approach The report said that the following factors contributed to the sector [of] Runway 28 because it did not correspond to accident: the actual visibility; [and,] • “The valid visual minimums at the time of the accident Avro 146-RJ85/100s, Boeing MD-83s, Embraer EMB-145s and were inappropriate for a decision to use the standard Saab 2000s — and had about 3,500 employees. VOR/DME [Runway 28] approach.” The commander, 57, held an airline transport pilot license and At the time of the accident, Crossair was engaged in regional had 19,555 fl ight hours, including 287 fl ight hours in type. He airline service, operated more than 80 airplanes — including began his fl ying career as a fl ight instructor and charter pilot. He was employed by Crossair as a Swearingen Metroliner pilot in 1979 and by Horizon Swiss Flight Academy as a part-time fl ight instructor in 1981.

“At his own request, he left Crossair on 31 May 1982,” the report said. “The commander’s performance was assessed by Crossair as above average.”

After leaving Crossair, the commander fl ew a as a contract pilot and as a part-time pilot for the company. On Jan. 1, 1994, he returned to full-time employment with Crossair. He continued to work as a contract fl ight instructor for Horizon Swiss Flight Academy. The report said that the commander occasionally conducted instructional fl ights for the academy in the morning and line fl ights for the airline in the afternoon.

The Crossair operations manual required that fl ight time and duty time accumulated by fl ight crewmembers during service with other companies be included in calculations of fl ight time and duty time for the airline.

“Neither Crossair nor the Horizon Swiss Flight Academy carried out any supervision of fl ying time and rest time across different companies,” the report said.

In 1995 and in 1996, the commander failed conversion courses for the McDonnell Douglas MD-80. The report said that he had diffi culty using the MD-80’s digital fl ight guidance system and that he demonstrated inadequate manual control of the airplane and “a limited ability to analyze and to take decisions at the appropriate time.” British Aerospace Avro 146-RJ100 The report said that a review of the commander’s career at British Aerospace (BAe) Regional Aircraft (now part of BAE Crossair showed that “he did not always strictly adhere to Systems) introduced the BAe 146 short-range transport standard operating procedures.” The following incidents were airplane in 1983. The Avro 146-RJ100, a lengthened version cited: of the airplane assembled by Avro International Aerospace, has four AlliedSignal (now Honeywell) LF507 turbofan engines, each producing 31.14 kilonewtons (7,000 pounds • The commander erroneously had believed that a Saab static thrust). 340’s landing gear could not be retracted with the The airplane accommodates two fl ight crewmembers, two airplane’s weight on its wheels. While conducting an cabin crewmembers or three cabin crewmembers, and 85 aircraft-systems-training session on Feb. 21, 1990, the passengers to 112 passengers. commander selected the landing-gear-lever downlock- Maximum takeoff weight is 46,040 kilograms (101,500 release button, and the student pilot moved the landing- pounds). Maximum landing weight is 40,144 kilograms gear lever to the retract position. The landing gear (88,500 pounds). Long-range cruising speed at 35,000 retracted, and the airplane was destroyed. The airline feet is 389 knots. Range with maximum payload is 2,130 kilometers (1,150 nautical miles). Stall speed with 33 degrees relieved the commander of his instructor’s duties; of fl ap is 95 knots.♦ • During a route check on June 25, 1991, the commander Source: Jane’s All the World’s Aircraft did not comply with an air traffi c control (ATC) airspeed restriction and fl ew the airplane into wake turbulence

2 FLIGHT SAFETY FOUNDATION • ACCIDENT PREVENTION • JUNE 2004 from a Boeing 747. He also omitted the approach check After a rest period of 10 hours and 59 minutes, the commander and before-landing check, and landed the airplane with returned to the airport at 0830 and conducted instrument a fl ight attendant standing in the cabin; training fl ights with student pilots for the academy from 1034 to 1327. • A copilot told investigators that in December 1995, he conducted an instrument approach in IMC with the “On the two days preceding the accident, the commander had commander in which a descent rate of 4,000 feet per clearly exceeded the permitted maximum duty times and had minute and an airspeed of 200 knots were maintained to slightly undercut the prescribed rest time the night before the 300 feet radio altitude. The overspeed-warning system accident,” the report said. “The accident happened at the end and the ground-proximity warning system (GPWS) had of a day in which the commander had been awake for 15 hours been disengaged before the approach was begun; and, [and] on duty for more than [13.5] hours. … The bad weather may have further increased the strain throughout the day and • After the accident in Zürich, Crossair learned about an led to greater fatigue.” incident on March 21, 1999, in which the commander conducted a visual approach in mountainous terrain to an The copilot began duty for Crossair at 1250 the day before the airport in Italy that was 50 kilometers (27 nautical miles) accident. He conducted four scheduled fl ights for Crossair and south of the destination in Germany. On fi nal approach, was off duty at 2305. The copilot was on duty for 10 hours and passengers observed road signs in Italian. The commander 15 minutes that day. conducted a go-around and fl ew the airplane through a mountain pass to the scheduled destination. “The copilot’s spouse stated that the copilot described this working day as very stressful and had felt very exhausted,” In 2001, the commander completed a conversion course for the report said. the Avro 146-RJ100. The report said that the proficiency check forms completed After a rest period of 18 hours and 15 by instructors during the conversion “On the two days minutes, the copilot began duty for Crossair course and route training contained only at 1720 on the day of the accident. The fl ight positive comments about the commander’s preceding the accident, crew was scheduled to conduct a fl ight from performance. Zürich to Berlin, Germany, and then to the commander had return to Zürich. The scheduled departure “No mistakes were pointed out, and no clearly exceeded the time from Zürich was 1820; the actual items were mentioned that the commander departure time was 1854. The crew landed could have improved,” the report said. permitted maximum the airplane in Berlin at 2025.

The report said that the different evaluations duty times.” “No refueling took place since the aircraft of the commander’s performance during his still had 5,650 kilograms [12,456 pounds conversions and attempted conversions to of] fuel on board (actual block fuel),” the different airplanes indicated that “certain experts and fl ying report said. “For the return fl ight [to Zürich], according to the instructors from the operator applied different benchmarks and fl ight plan, a fuel amount of 4,893 kilograms [10,787 pounds] did not recognize the defi cits which were present. The operator (minimum block fuel) was required.” also did not really manage to put the various occurrences during the commander’s career into a broader context, to recognize A ramp-handling agent who conversed briefly with the common features and basic patterns or to take appropriate commander said that the commander’s behavior was normal, measures.” with “no signs of stress or urgency.”

The copilot, 25, held a commercial pilot license and had 490 The crew received taxi instructions from ATC at 2056. While fl ight hours, including 348 fl ight hours in type. He was employed holding on a taxiway, the crew was told to taxi the airplane onto by Crossair after he earned his commercial pilot license at the runway and to hold for takeoff clearance. The taxiway stop Horizon Swiss Flight Academy in 2000. The commander had bar lights remained illuminated, however, and the crew refused conducted instrument-training fl ights with the copilot when the to taxi onto the runway until the lights were extinguished. The copilot was a student at the academy. crew began the takeoff at 2101.

From 0715 to 0957 the day before the accident, the commander The commander, the pilot fl ying, used the automatic fl ight control conducted two instrument-training fl ights with student pilots system (AFCS). Digital fl ight data recorder (DFDR) data showed for the Horizon Swiss Flight Academy. From 1202 to 2101, that the AFCS functioned normally throughout the fl ight. he conducted four scheduled fl ights for Crossair and was off duty at 2131. The commander was on duty for 15 hours and The copilot conducted radio communications with ATC 31 minutes that day. in English. The pilots conversed in Swiss German. The

FLIGHT SAFETY FOUNDATION • ACCIDENT PREVENTION • JUNE 2004 3 cockpit voice recorder (CVR) recording began at 2136, when At 2153, ATC issued vectors to the Zürich East (ZUE) VOR, the airplane was in cruise fl ight at Flight Level (FL) 270 which is northeast of the airport, and told the crew to descend (approximately 27,000 feet). The pilots discussed automatic to 6,000 feet. terminal information service (ATIS) information “Kilo,” which said that the instrument landing system (ILS) approach The VOR/DME Runway 28 approach procedure required the to Runway 14 was being used at Zürich Airport, surface winds fl ight to cross the ZUE VOR and then to track the ZUE VOR were from 190 degrees at four knots, visibility was 3,000 meters 178-degree radial outbound at 5,000 feet until intercepting the (9,843 feet) in light snow and there were a few clouds at 500 fi nal approach course — 275 degrees inbound to the feet above ground level (AGL), scattered clouds at 1,500 feet (KLO) VOR, which is on the airport. AGL and a broken ceiling at 2,200 feet AGL. While conducting an approach check at 2157, the pilots set and The crew did not receive ATIS information “Lima,” which cross-checked their altimeter settings and altimeter indications. said that the VOR/DME Runway 28 approach was being used. The copilot told the commander that the fuel-panel gauges Weather conditions were the same as those reported by ATIS indicated that 3,200 kilograms (7,055 pounds) of fuel remained information Kilo. in the fuel tanks.

At 2140, ATC told the crew to descend to FL 240. At 2142, At 2158, ATC cleared the crew to conduct the VOR/DME ATC told the crew to continue the descent to FL 160. The Runway 28 approach and to reduce airspeed to 180 knots. Soon commander briefed the copilot on the ILS Runway 14 thereafter, the crew was told to establish radio communication approach and told the copilot to set up the navigation radios with Zürich Tower. At the time, the crew was conducting a for the ILS approach. descent to 4,000 feet (per the published approach procedure) and a right turn to intercept the fi nal approach course. The During the approach briefi ng, the copilot told the commander airplane was approximately 11 nautical miles (20 kilometers) that indicated airspeed was increasing toward the maximum east of the airport. limit (redline). During the turn, the commander told the “I believe that our speed is going somewhat During the turn, the copilot that he had visual contact with the into the red,” the copilot said. commander told the ground. The report said that this statement indicated that the pilot “was looking outside “Yes, it ran away,” the commander said. copilot that he had the cockpit for at least some of the time “Sorry. Have to bring it back a bit.” [rather than] controlling the aircraft using visual contact with instruments.” At 2144, ATC told the crew to reduce the ground. airspeed to 240 knots and to descend to The published minimums for the VOR/DME FL 130. At 2147, the crew was told to Runway 28 approach were 2,390 feet (974 establish radio communication with Zürich feet above runway touchdown zone elevation) Arrival East. and 2,000 meters runway visual range (RVR). The report said that the cloud bases near the airport were not uniform. Pilot reports During his fi rst radio transmission to Zürich Arrival East, the indicated that there were scattered clouds east of the airport at copilot said that the crew had received ATIS information Kilo. 500 feet above airport elevation and a broken ceiling at 1,000 feet The controller did not tell the crew that ATIS information above airport elevation; airport elevation was 1,416 feet. “Mike” was current but said that the crew could expect to conduct the VOR/DME Runway 28 approach. “When fl ying just below the main cloud base, forward visibility from the cockpit was greatly restricted because of the patches of At 2150, ATIS information “November” was broadcast. stratus,” the report said. “Below the cloud layers, meteorological Visibility had increased to 3,500 meters (11,484 feet), and the visibility was approximately 4.0 kilometers [2.5 statute miles]; base of the broken ceiling had lowered to 1,500 feet AGL. in light precipitation and near the cloud base, it was reduced to about 2.0 kilometers [1.2 statute miles].” “These changes were not communicated to the crew by the Zürich Arrival East sector air traffi c controller,” the report Pilot reports indicated that moderate icing conditions existed said. below FL 140 and that severe icing conditions existed from FL 120 to FL 80. The surface temperature was slightly above At 2151, the crew began to fl y a holding pattern over a navigation freezing, and precipitation in the form of snow mixed with rain fi x north of the airport. While holding, the commander briefed was observed in the area. the copilot on the VOR/DME Runway 28 approach. The copilot told the commander that he had conducted the approach “a At 2203, the crew of an EMB-145 landed the airplane couple of times.” on Runway 28 and told the tower controller that weather

4 FLIGHT SAFETY FOUNDATION • ACCIDENT PREVENTION • JUNE 2004 conditions were “pretty minimum” and that they had acquired At 2205:21, the fi rst offi cer told the tower controller that the visual contact with the runway about 2.2 nautical miles (4.1 airplane was established on the VOR/DME fi nal approach kilometers) from the KLO VOR (about 1,700 meters [5,578 course. At the time, the airplane was crossing the 6.0-nautical- feet] from the runway approach lights). mile DME fi x at 3,240 feet. The commander said, “Six miles, three three [3,300 feet] is checked.” “This aircraft was the fi rst that evening to execute the standard [i.e., not radar-vectored by ATC] VOR/DME approach [to The report said that the commander either did not observe that Runway] 28,” the report said. “The commander of the accident the airplane was 120 feet lower than the published minimum fl ight was aware of this report from [the EMB-145 crew].” altitude for that segment of the approach or considered that the altitude deviation was tolerable. The fi nal approach fi x (FAF) was 8.0 nautical miles (14.8 kilometers) DME from the KLO VOR. After crossing the FAF, “This was probably the beginning of an at least partial loss of a descent from 4,000 feet to 3,360 feet was authorized by the awareness of the situation,” the report said. published approach procedure. After crossing the 6.0-nautical- mile (11.1-kilometer) DME fi x, a descent to the MDA — 2,390 There was no further discussion by the fl ight crew of the feet — was authorized. The missed approach point was at the airplane’s distance from the VOR. 2.0-nautical-mile (3.7-kilometer) DME fi x. At 2205:36, the commander told the copilot to extend the fl aps At 2204, the copilot said, “We’re coming to eight miles, so we to 33 degrees. can leave four thousand.” The commander acknowledged the information and told the copilot to set 6,000 At 2205:55, the commander said, “Two four feet, the altitude required by the published [2,400 feet]. We have ground contact.” missed approach procedure, in the mode- control panel (MCP). The commander also A terrain awareness and The copilot said, “Yes.” told the copilot to extend the landing gear warning system (TAWS) and to extend the fl aps to 24 degrees. The commander said, “Someone [i.e., the would have detected an EMB-145 crew] said he saw the runway Company procedure at the time required late here. Approaching minimum descent flight crews to set the missed approach excessive terrain-closure altitude. Here, we’ve got some ground altitude in the MCP soon before crossing rate and would have contact.” the FAF. warned the crew of The EMB-145 was one of two Crossair “In former times, … the MDA was set on the airplanes that had been landed while MCP during the fi nal approach,” the report the hazard. the accident crew was conducting the said. “This [former] procedure established approach. a safety net, because an automatic level-off at the MDA was executed, without pilot intervention, provided “It cannot be excluded that this fact generated a certain pressure the autopilot was engaged.” to succeed or at least encouraged the hope that a landing was possible under the prevalent weather conditions,” the report At the beginning of the descent, the Avro’s indicated airspeed said. was 160 knots and its rate of descent was 1,000 feet per minute. The rate of descent later was increased to 1,200 feet per minute At 2206:10, as the airplane was descending through the MDA, and was maintained at 1,200 feet per minute until just before the commander said, “Two four, the minimum. I have ground the airplane struck terrain. contact. We’re continuing at the moment. It appears we have ground contact. We’re continuing on.” At the time, the airplane The descent rate was not sufficient to trigger a GPWS was 4.4 nautical miles (8.1 kilometers) from the VOR and 3.5 excessive-sink-rate warning or a GPWS excessive-terrain- nautical miles (6.5 kilometers) from the runway threshold. closure-rate warning. The report said that a terrain awareness and warning system (TAWS) would have detected an excessive “The recordings of the [CVR] prove that communication and terrain-closure rate and would have warned the crew of the cooperation between the commander and the copilot took place hazard.1 calmly and professionally,” the report said. “The pronounced calmness which the commander exhibited almost continuously “If the aircraft in landing confi guration approaches the ground had very probably created in the copilot the impression of an too far away from the runway, a visual [warning] and acoustic experienced superior who was acting prudently and consciously. warning are generated,” the report said. “This is possible This may have been one of the main reasons why the copilot did because the TAWS has access to a topographical database of not intervene when … the commander continued the descent the area around the airport.” below the minimum altitude for the approach.”

FLIGHT SAFETY FOUNDATION • ACCIDENT PREVENTION • JUNE 2004 5 The Crossair operations manual said that pilots could continue nautical miles (seven kilometers) from the runway threshold. a nonprecision approach below MDA if one of the following The controller observed the airplane’s altitude readout only once visual references was “distinctly visible” and “identifi able”: — when the airplane was six nautical miles from the runway threshold at about 3,600 feet. • “Elements of the approach lights system; The controller told investigators, “I did not carry out any more • “[Runway] threshold; altitude checks later. I merely monitored the continuing fl ight path. The reason I did not carry out any deliberate altitude • “Threshold marking; checks was that the aircraft was using its own navigation [to conduct the approach] and, in my opinion, in this status, there • “Threshold lights; was no need for me to carry out such altitude checks as part of radar-monitoring.” • “Threshold identifi cation lights; The report said that although the ATC facility duty plan called • “Visual glide [path] indicator; for four approach controllers and four airport controllers to be on duty, one approach controller and two airport controllers • “Touchdown zone or touchdown zone markings; were on duty at the time.

• “Touchdown zone lights; The airport had MSAW equipment to help controllers monitor approaches to Runway 14 and to Runway 16 but did not have • “Runway edge lights; [or,] MSAW equipment to help controllers monitor approaches to Runway 28. MSAW equipment provides a visual warning and • “Other visual reference as published in [the route an aural warning when an aircraft descends below specifi c manual].” minimum altitudes during an approach.

The report said that the crew used a At 2206:31, the commander said, “Two Jeppesen approach chart that did not depict The airport … did not thousand.” The GPWS then announced two obstacles that were shown on the Swiss “minimums” when the airplane was at 300 Aeronautical Information Publication (AIP) have MSAW equipment feet radio altitude, the decision height that approach chart. to help controllers had been selected on the commander’s radio altimeter. “[The airplane] collided with the most monitor approaches to northerly of these two obstacles, a hill The controller cleared the crew to land the with an obstacle light at 1,880 feet,” the Runway 28. airplane on Runway 28. The report said report said. “It cannot be excluded that the that while the copilot was acknowledging commander would have reconsidered his the clearance, the commander said quietly, decision to descend below the MDA without suffi cient visual “Make a go-around?” Two seconds later, at 2206:34, the references if these obstacles had been visible on the approach commander said, “Go around.” chart.” The copilot said, “Go around.” The airplane was at 2,150 feet at 2206:22, when the GPWS announced 500 feet radio altitude. The commander voiced The CVR recorded the sound of the autopilot being disengaged; an expletive and said, “Two miles, he said, he sees the the autothrottle system remained engaged. DFDR data indicated runway.” At the time, the airplane was 3.1 nautical miles that engine speed began to increase one second before the CVR (5.7 kilometers) from the runway threshold. The report said began recording the sounds of impact at 2206:36. The CVR that the crew would not have been able to see the runway recording ended soon thereafter. environment and that the captain likely did not have visual contact with the ground. The airplane was in landing confi guration, the pitch attitude had been changed from two degrees nose-down to five “It is highly probable that in this phase, the commander was degrees nose-up, and the rate of descent had decreased from trying to re-establish visual contact with the ground,” the report 1,200 feet per minute to zero feet per minute when the airplane said. “Since he did not mention further visual references, it must struck treetops near the summit of a hill. The airplane then be assumed that he no longer had any.” struck the ground, broke into several pieces and began to burn. The controller told investigators that he observed the airplane on his radar display when the airplane was nine nautical miles (17 “Because of this intense fi re, the accident was survivable only kilometers), six nautical miles (11 kilometers) and about four by chance,” the report said.

6 FLIGHT SAFETY FOUNDATION • ACCIDENT PREVENTION • JUNE 2004 The debris path extended about 1,000 meters (3,281 feet) from approaches should be adapted, so that a fi nal approach the point of initial contact with the trees. with the necessary visual references is possible from the [VDP]; “The impact and the subsequent intense fi re destroyed the cockpit, the front part of the fuselage, the central part of • “Many [airports] in Switzerland have rises in the terrain in the fuselage and large sections of both wings,” the report their immediate environment which are clearly above the said. “Only the aft section of the fuselage, which was torn reference height of the [airport]. Obstacles on approach off complete with the elevator unit and rudder unit, was not can be made more apparent by using a side-view affected by the fi re.” representation of the terrain along the approach path. … [FOCA] should check whether the terrain profi le along The report included the following statements from survivors: the approach path should be entered in the approach charts for all categories of instrument approach; • “The aircraft fl ew into trees, a wing broke off, and the aircraft caught fi re. But then, it gently hit the ground, • “On the day before the accident, the commander was on shook, made a ‘bang’ and came down at an angle”; duty for 15 hours [and] 31 minutes because he had already completed two IFR [instrument fl ight rules] training • “Suddenly, there was a thud … . On the right side, fl ights before fl ying the four sectors for the operator. The I noticed a fireball outside the aircraft. Up to that prescribed rest time was not complied with. At the time of moment, I thought everything was going normally. Then the accident, the commander had already been on duty for it rumbled and jolted like a roller coaster. Suddenly, it 13 hours and 37 minutes because he had made three IFR went quiet”; training fl ights prior to the accident fl ight. The fl ying duty records show that this combination of training activity • “There was a sudden crash, and a fi reball came at us at and assignment as an air transport pilot on the same day great speed from the nose”; and, was not a rarity. No inter-company check on crew times was carried out. As the accident shows, the commander • “Suddenly, a loud crashing noise could be heard, and the of the aircraft involved in the accident exhibited signs aircraft shook violently. I immediately looked forward of fatigue in his behavior. … [FOCA], together with the and saw through the open cockpit door and the cockpit operator, should check how a complete check on total windscreens that outside the aircraft, a real shower of fl ying duty time and rest time can be guaranteed; sparks was rising. Next moment, there was a massive impact.” • “The investigation showed that even before the accident, there were crews who did not follow guidelines and Based on the fi ndings of the accident investigation, AAIB on procedures. The operator’s efforts in the area of Oct. 2, 2003, made the following recommendations to the fl ight safety, as well as the monitoring measures of Swiss Federal Offi ce for Civil Aviation (FOCA; Bundesamt [FOCA], were not adequate to detect and prevent these für Zivilluftfahrt); [as of June 4, 2004, responses by FOCA to occurrences. Within the framework of the quality systems the recommendations were pending]: required according to the provisions of the Joint Aviation Authorities JAR-OPS [Joint Aviation Requirements — • “The visual descent point (VDP) is the point at the Operations] 1.035 on the commercial carriage of persons [MDA] of a nonprecision approach from which a and goods in aircraft, [FOCA] should demand procedures normal visual approach to the runway is possible. If from the operators which indicate and eliminate defi cits a glide path indicator (e.g., a precision approach path in the behavior and working practices of fl ight crews by indicator [PAPI]) is present, the VDP is the intersection means of internal company measures, and should monitor point of this glide path with the MDA. In the case of a these procedures; [and,] nonprecision approach, only the missed approach point is defi ned. … [FOCA] should check the extent to which • “The investigation showed that for a long period, a [VDP] should be added to the approach charts for the operator did not manage to determine the actual nonprecision approaches; capabilities of a crewmember. The experts responsible for administering skill tests, profi ciency checks and line • “The investigation has shown that the minimum visual checks, [and] who were employed by the operator and ranges in force at the time of the accident for the who carried out these tests on behalf of [FOCA], were in standard VOR/DME approach [to Runway] 28 are not the majority not able to detect defi cits and weaknesses, appropriate. … A minimum visual range can only be so these were able to have an infl uence on the accident. termed appropriate if it makes it possible to carry out … [FOCA] should arrange for qualifi cations [checks] the fi nal approach with the necessary visual references and profi ciency checks to be administered, at least on from the [VDP]. … [FOCA] should check the extent to a random-sample basis, by inspectors or independent which the valid minimum visual ranges for nonprecision experts from [FOCA].”

FLIGHT SAFETY FOUNDATION • ACCIDENT PREVENTION • JUNE 2004 7 The report said that Crossair, which became part of Swiss 2. Flight Safety Foundation (FSF) criteria for reducing approach- International Air Lines in 2002, established a program to and-landing risks are included in the FSF Approach-and-landing reduce approach-and-landing risks based on criteria developed Accident Reduction (ALAR) Tool Kit. The tool kit provides on by Flight Safety Foundation.2 The program included 81 compact disc (CD) a unique set of pilot briefi ng notes, videos, actions, including revisions of operating manuals, installation presentations, risk-awareness checklists and other tools designed to help prevent approach-and-landing accidents (ALAs) and of improved aircraft equipment and changes to crew-training controlled fl ight into terrain (CFIT). The tool kit is the culmination procedures and crew-testing procedures. The airline also of the Foundation-led efforts of more than 300 safety specialists established a safety advisory board to evaluate its operating worldwide to identify the causes of ALAs and CFIT, and to develop 3 standards and practices. ♦ practical recommendations for prevention of these accidents. The FSF ALAR Tool Kit is a compilation of work that was begun in [FSF editorial note: This article, except where specifi cally 1996 by an international group of aviation industry volunteers noted, is based on the English translation of the Swiss Aircraft who comprised the FSF ALAR Task Force, which launched the Accident Investigation Bureau (AAIB; Büro für Flugunfall- second phase of work begun in 1992 by the FSF CFIT Task Force. untersuchungen) Investigation Report of the Aircraft Accident CFIT occurs when an airworthy aircraft under the control of the Investigation Bureau on the accident to aircraft AVRO 146- fl ight crew is fl own unintentionally into terrain, obstacles or water, RJ100, HB-IXM, operated by Crossair under fl ight number usually with no prior awareness by the crew. This type of accident can occur during most phases of fl ight, but CFIT is more common CRX 3597, on 24 November 2001 near Bassersdorf/ZH. The during the approach-and-landing phase, which begins when an 161-page report contains illustrations and appendixes.] airworthy aircraft under the control of the fl ight crew descends below 5,000 feet above ground level (AGL) with the intention to Notes conduct an approach and ends when the landing is complete or the fl ight crew fl ies the aircraft above 5,000 feet AGL en route to 1. Terrain awareness and warning system (TAWS) is the term used by another airport. the European Joint Aviation Authorities and the U.S. Federal Aviation Administration to describe equipment meeting International Civil 3. Members of the Swiss International Air Lines safety advisory board Aviation Organization standards and recommendations for ground- included: Christian Josef Krahe, a former engineering test pilot for proximity warning system (GPWS) equipment that provides predictive Airbus; Karel Ledeboer, a former executive with KLM Royal Dutch terrain-hazard warnings; enhanced GPWS and ground collision ; and Stuart Matthews, FSF president and CEO. The work of avoidance system are other terms used to describe TAWS equipment. the independent safety advisory board is ongoing.

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We Encourage Reprints Articles in this pub lica tion, in the interest of aviation safety, may be reprint ed, in whole or in part, but may not be offered for sale, used commercially or distributed electronically on the Internet or on any other electronic media with out the ex press writ ten per mis sion of Flight Safety Foun da tion’s di rec tor of publications. All uses must credit Flight Safety Founda tion, Accident Prevention, the specifi c article(s) and the author(s). Please send two copies of the reprinted material to the director of pub lica tions. These restrictions apply to all Flight Safety Foundation publications. Reprints must be ordered from the Foundation. What’s Your Input? In keeping with the Foundation’s independent and nonpar ti san mission to disseminate objective safety in forma tion, FSF publications solicit credible contri bu tions that foster thought-provoking dis cussion of aviation safety issues. If you have an article proposal, a completed manuscript or a technical paper that may be appropriate for Accident Prevention, please contact the director of publications. Reason able care will be taken in handling a manu script, but Flight Safety Foundation assumes no responsibility for material submitted. The publications staff reserves the right to edit all pub lished submis sions. The Foundation buys all rights to manuscripts and payment is made to authors upon publication. Contact the Publications De part ment for more in for ma tion. Accident Prevention Copyright © 2004 by Flight Safety Foundation Inc. All rights reserved. ISSN 1057-5561 Suggestions and opinions expressed in FSF pub li ca tions belong to the author(s) and are not neces sar i ly endorsed by Flight Safety Foundation. This information is not intended to supersede operators’/manufacturers’ policies, practices or requirements, or to supersede government regulations. Staff: Roger Rozelle, director of publications; Mark Lacagnina, senior editor; Wayne Rosenkrans, senior editor; Linda Werfelman, senior editor; Rick Darby, associate editor; Karen K. Ehrlich, web and print production coordinator; Ann L. Mullikin, pro duc tion designer; Susan D. Reed, production specialist; and Patricia Setze, librarian, Jerry Lederer Aviation Safety Library Subscriptions: One year subscription for twelve issues includes postage and handling: US$240. Include old and new addresses when requesting address change. • Attention: Ahlam Wahdan, membership services coordinator, Flight Safety Foundation, Suite 300, 601 Madison Street, Alexandria, VA 22314 U.S. • Tele phone: +1 (703) 739-6700 • Fax: +1 (703) 739-6708.

8 FLIGHT SAFETY FOUNDATION • ACCIDENT PREVENTION • JUNE 2004